Clinical Tracks

Take-away points: Co-management does not always result in better or more efficient care. Common arguments in favor of having hospitalists involved, such as improved outcomes and leveraging scarce specialist resources, each have a counter-argument that should be carefully considered.

In assuming co-management of orthopedic or neurosurgical patients, Dr. Siegal points out: “We’re managing patients we were never trained to manage. Subspecialties know how to do this type of care. Why step in, learn new skills, and practice them on living patients?”

Dr. Siegal summarized his concerns with some clear caveats: “Be rigorous about defining your co-management responsibilities; admit that some patients don’t need us; concentrate on leveraging your own scarce resources; and recognize that it’s sometimes better for a surgeon to see his or her patient.”

If and when you do assume co-management responsibilities, he advised, ask questions, including “Why are we being asked to participate?” “Will we make a difference?” and “What might we screw up?”

Take-away points: Dr. Pile’s presentation began with the evolving topic of methicillin-resistant Staph aureus (MRSA). He traced the evolution of nosocomial and community-associated strains of MRSA and detailed the ongoing shifts in the distribution of community-associated MRSA (CA-MRSA). Particular attention was given to the ongoing movement of CA-MRSA out of the community and into the hospital setting, the recent emergence of multidrug resistant CA-MRSA on the East and West coasts, and MRSA colonization.

He also touched on the emerging understanding that vancomycin is a less-than-ideal treatment for serious MRSA infections, and outlined the potential utility of alternative agents old and new. He then addressed catheter-related bloodstream infections, including optimal diagnostic methods, evidence-based methods of prevention, and treatment strategies.

He stressed that the still-underutilized therapeutic modality of antibiotic lock therapy clearly appears to increase the likelihood of successfully salvaging infected catheters, and discussed the fact the responsible pathogen helps inform the decision to remove or retain an infected catheter. He closed by pointing out that revised guidelines for the treatment of catheter-related bloodstream infections from the Infectious Diseases Society of America should be released shortly.

Dr. Bolger believes hospitalists at a large academic teaching center should have the ability to affect their compensation; therefore, those who contribute more should be compensated more. His institution uses a base-incentive plan that rewards for core values including teaching, innovation, and quality.

Dr. George of the multistate hospital medicine program Cogent Healthcare discussed her organization’s compensation plan of a base salary plus a bonus of approximately 20% of salary for incentives.

Take-away points: These academic hospitalist leaders stressed research in this session. Research is critical to the success of hospital medicine. You can support research by building research expertise among your staff and creating (or borrowing) an infrastructure for research. Get your entire group involved, with the goal of producing at least two scholarly works a year. Invite other subspecialists and institutions to participate in your research. You also must offer salary support for dedicated scholarship time.

Take-away points: Retitled “BOOSTing Care Transitions,” this session focused on problems with discharging patients and outlined Project BOOST: Better Outcomes for Older adults through Safe Transitions. The BOOST toolkit includes resources for identifying high-risk patients; preparation for the patient and caregiver including follow-up plans; and a discharge summary communication. Specific tools include GRATE, a Geriatric Risk Adjusted Transition Evaluation; a 6P Risk Scale to be used on admit and discharge; a Risk Adjusted Checklist; and GAP, Geriatric Assessment of Preparedness for on admit, near discharge and at discharge. The toolkit is available online in the SHM Resource Rooms at www.hospitalmedicine.org.

Take-away points: Relevant data from the “Society of Hospital Medicine 2007-08 Survey: The Authoritative Source on the State of the Hospitalist Movement” were reviewed, with many caveats noted as the pediatric portion still is being analyzed. Pediatric hospitalists make less money than their adult-patient counterparts, with a total compensation of $144,600 compared with $183,900. They reported fewer patient encounters and work fewer hours overall. These differences are subject to closer examination. “Is this really a decrease in productivity and the work that we do, or does this reflect the fact that virtually no ‘private practice hospitalists’ responded?” Dr. Percelay asked.

Take-away points: To help fill the gap in information on pediatric care, Dr. Narang designed a clinical pathway for admitting an increasing number of pediatric patients with skin and soft-tissue infection (abscess) based on evidence and expert opinion. This pathway was shared with 100 pediatric providers in Louisiana. The results of implementing the pathway in his institution showed a reduction in other, less efficient treatments and tests, a 25% decrease in length of stay for these patients and a 20% decrease in cost—both in three years.